Recurrent suppurative thyroiditis due to pyriform sinus fistula: a case report

Acute suppurative thyroiditis is a rare disease, particularly in childhood. We present a case with recurrent acute suppurative thyroiditis due to a pyriform sinus fistula originating from the fourth branchial pouch. The typical symptoms of a piriform sinus fistula are recurrent left-sided pain and swelling of the neck with signs of acute bacterial inflammation. Diagnosis should be made by high resolution ultrasound, barium meal studies and endoscopic examination. During acute exacerbations treatment with antibiotics is indicated, but permanent cure can only be attained by complete fistulectomy.     

Acute suppurative thyroiditis in young children

We report two children with acute suppurative thyroiditis (AST). They presented with typical features of AST, which include fever, painful goiter and biochemical euthyroidism. An anatomical defect predisposed to thyroid infection, pyriform sinus fistula, was identified in one patient. Both patients responded well to surgical pus drainage and antibiotic treatment. Anatomical defects must be sought in all children with AST to perform specific surgical treatment and prevent recurrent infection.     

Light guided procedure for congenital pyriform sinus fistula; new and simple procedure for impalpable fistula

Pyriform sinus fistula causes acute suppurative thyroiditis, and there is a risk of recurrence if the sinus tract is not excised completely. The tract should be dissected as high as possible toward the pyriform fossa. We report our devised technique “the light guided procedure” for the impalpable fistula. A bronchoscope was inserted into the pyriform sinus fistula with the help of a gastrofiberscope positioned at the larynx. The tract of the fistula was identified with the help of the light from the bronchoscope. We were able to reach the proximal end of the fistula, directly. This procedure is easy, safe, and minimally invasive.     

Acute thyroiditis caused by Eikenella corrodens and abnormality of the left pyriform sinus

A case of suppurative thyroiditis is reported. The initial course was insidious and mimicked De Quervain subacute thyroiditis. The abscess was surgically drained. It contained numerous Eikenella corrodens bacilli. Fibroscopy of pharyngo-laryngeal region showed that the left pyriform sinus was abnormal. Surgical removal of a fistula of the fourth branchial pouch was performed in order to prevent recurrence of the thyroiditis.     

Congenital piriformo-thyroid fistula as a cause of recurrent suppurative thyroiditis

A previously healthy five year old boy presented with suppurative, febrile thyroiditis of the left lobe with pronounced general and local signs of inflammation, normal thyroid function and lack of thyroid antibodies. Intravenous antibiotic therapy improved the condition quickly. Six and nine months later however recurrent left lobe thyroiditis occurred. Endoscopic examination showed an internal fistula from the left piriform sinus to the left thyroidal lobe which was cut out. The case report confirms previous communications, that recurrent suppurative thyroiditis is nearly always caused by a piriform sinus fistula, probably a fourth pharyngeal pouch remnant which can be cured surgically.     

Cervical infection secondary to pyriform sinus fistula of branchial origin

Complete third branchial arch anomalies are rare and have been described only in case reports, affecting mainly children and typically presenting as a cervical inflammatory process. Anomalies of the third and fourth branchial apparatus, though rare, usually present as sinuses/incomplete fistulas of pyriform sinus or recurrent suppurative thyroiditis. A 6‐year‐old girl presented with a small opening on the left side of her anterior neck, which had been present since birth and was associated with recurrent infection. She had no history of incision and drainage of swelling. Computed tomography with contrast injection into the cervical opening revealed a fistulous tract extending from the cervical neck skin to the pyriform fossa. Complete excision of the fistulous tract and left hemithyroidectomy were performed. There was no recurrence at 22 months of follow‐up.     

Thyroiditis. Differentiation of acute suppurative and subacute. Case report and review of the literature

Acute suppurative thyroiditis is rarely seen during childhood. The classic clinical features of this illness (fever, neck pain, and a swollen, tender mass over the thyroid gland) can differentiate acute thyroiditis from the more common subacute thyroiditis. In less typical cases, however, this distinction can be difficult. An adolescent male presented with a swollen, tender thyroid gland. Atypical laboratory findings and the lack of fever and toxicity delayed the diagnosis and treatment of acute suppurative thyroiditis. A review of the pediatric literature summarizes clinical and diagnostic features valuable in the differential between acute suppurative thyroiditis and subacute thyroiditis in childhood. The important contribution of fistulae between the piriform sinus and thyroid gland to the pathogenesis and acute suppurative thyroiditis is emphasized. Such a fistula should be sought in every patient in whom this entity is diagnosed.     

Acute suppurative thyroiditis in children secondary to pyriform sinus fistula

Acute suppurative thyroiditis (AST), a potential complication of pyriform sinus fistula (PSF), is a rare clinical condition as the thyroid gland is remarkably resistant to infections. Lack of awareness of the entity contributes to the rarity and frustrating recurrences. We performed a retrospective review of all cases of AST due to PSF treated at our institution over a 10-year period. The clinical data, investigations, operative findings and procedures, microbial culture reports and follow-up were recorded and analyzed. Between January 1997 and September 2006, 12 cases (8 males and 4 females) of AST due to PSF were treated. Nine patients (75%) underwent successful complete excision, seven of whom had initial incision and drainage procedures. In three patients (25%) with recurrence, one underwent complete excision at a later procedure, one patient had multiple recurrences with six incision and drainage procedures and two failed attempts of excision of PSF before final successful complete excision. The third patient is awaiting re-excision of the PSF tract. All patients, except the one awaiting re-excision, are well with no further recurrences during the follow-up period that ranged from 18 to 96 months (median, 46.5 months). AST due to PSF is a challenging entity in terms of diagnosis and management as recurrences are common despite meticulous dissection. High index of suspicion and radiological investigations such as barium studies and computed tomography scan aid in the delineation and excision of the fistulous tract.     

儿童梨状窝瘘反复发作的原因与胃镜辅助手术

目的分析儿童梨状窝瘘反复发作的原因，介绍胃镜辅助手术方法及其优越性。方法12例患儿。男8例，女4例，年龄2．5～9岁；曾行左颈部瘘管或囊肿切除术8例，左颈部反复感染者4例；吞钡造影、B超、CT、同位素扫描等检查诊断为梨状窝瘘。12例均行胃镜辅助瘘管切除术。取此前未经胃镜辅助而直接手术的8例临床资料作对照。结果经胃镜辅助切除瘘管，平均手术时间1h 35min，术后恢复顺利，随访无复发。对照组手术时间长，2例复发。结论缺乏对梨状窝瘘胚胎发生和病理过程的了解是治疗失误的主要原因，胃镜辅助手术是一种简便、有效的治疗手段。     

Pyriform sinus fistula

Pyriform sinus fistulae/sinuses are rare causes of recurrent cervical abscess, especially on the left side. They can also present as acute thyroiditis. Treatment in the form of simple incision and drainage is invariably unsuccessful, and the entity may be confused with the residual tract of a second branchial arch anomaly. We report a case of pyriform sinus fistula, and believe that this is only the second case report in India. We feel that greater awareness can lead to proper and appropriate diagnosis of this anomaly.     

Pyriform sinus fistula

Pyriform sinus fistulae/sinuses are rare causes of recurrent cervical abscess, especially on the left side. They can also present as acute thyroiditis. Treatment in the form of simple incision and drainage is invariably unsuccessful, and the entity may be confused with the residual tract of a second branchial arch anomaly. We report a case of pyriform sinus fistula, and believe that this is only the second case report in India. We feel that greater awareness can lead to proper and appropriate diagnosis of this anomaly.     

新生儿梨状窝瘘的诊治特点

目的 阐述新生儿梨状窝瘘这一少见疾病的诊治特点.方法 收集我院2001年7月至2010年1月收治的9例新生儿梨状窝瘘病例,分析其发病年龄、临床表现、辅助检查及临床治疗经过,总结其诊治特点和预后.结果 9例梨状窝瘘均为左侧.均以颈部囊性肿块就诊.8例为新生儿时期出现症状,1例为产前发现.5例颈部增强CT提示肿块中含有气体.新生儿时期手术治疗7例.随访时间6个月至9年,患儿临床均无反复感染或复发迹象.结论 新生儿的梨状窝瘘临床表现不同于儿童,常因颈部无痛性、囊性肿块就诊,缺少反复脓肿切开引流史.超声或CT检查中常可发现囊肿中含有气体影.新生儿早期手术瘘管结扎率高,部分需要胃镜辅助.治疗安全性可靠,术后复发率低且预后良好.     

新生儿梨状窝瘘的诊治特点

目的 阐述新生儿梨状窝瘘这一少见疾病的诊治特点.方法 收集我院2001年7月至2010年1月收治的9例新生儿梨状窝瘘病例,分析其发病年龄、临床表现、辅助检查及临床治疗经过,总结其诊治特点和预后.结果 9例梨状窝瘘均为左侧.均以颈部囊性肿块就诊.8例为新生儿时期出现症状,1例为产前发现.5例颈部增强CT提示肿块中含有气体.新生儿时期手术治疗7例.随访时间6个月至9年,患儿临床均无反复感染或复发迹象.结论 新生儿的梨状窝瘘临床表现不同于儿童,常因颈部无痛性、囊性肿块就诊,缺少反复脓肿切开引流史.超声或CT检查中常可发现囊肿中含有气体影.新生儿早期手术瘘管结扎率高,部分需要胃镜辅助.治疗安全性可靠,术后复发率低且预后良好.     

Congenital pyriform sinus fistula: A cause of acute left-sided suppurative throiditis and neck abscess in children

Acute bacterial thyroiditis or neck abscesses in children can be caused by infection through pyriform sinus fistulae which usually originate from the tip of the left pyriform sinus. They are thought to be remnants of either the third or fourth pharyngeal pouches. CT, ultrasound and gastrointestinal contrast studies are all useful in clarifying the pathological process and showing the extent.     

Successful endoscopic ablation of a pyriform sinus fistula in a child: case report and literature review

Recurrent thyroid infections are rare in children. When present, patients should be evaluated for anatomic anomalies such as pyriform sinus fistulae. We describe a 12-year-old girl with history of recurrent thyroid abscesses secondary to a pyriform sinus fistula and managed with concurrent endoscopic ablation and incision and drainage.     

Test characteristics and interpretation of cerebrospinal fluid gram stain in children

BACKGROUND: Few data exist regarding the test characteristics of cerebrospinal fluid (CSF) Gram stain among children at risk for bacterial meningitis, especially the rate of false positive Gram stain. METHODS: We conducted a retrospective cohort study of children seen in the emergency department of Children's Hospital Boston who had CSF obtained between December 1992 and September 2005. Patients who had ventricular shunts, as well as those who received antibiotics before CSF was obtained were excluded. Test characteristics of CSF Gram stain were assessed using CSF culture as the criterion standard. Patients were considered to have bacterial meningitis if there was either: (1) growth of a pathogen, or (2) growth of a possible pathogen noted on the final CSF culture report and the patient was treated with a course of parenteral antibiotics for 7 days or more without other indication. RESULTS: A total of 17,569 eligible CSF specimens were collected among 16,036 patients during the 13-year study period. The median age of study subjects was 74 days. Seventy CSF specimens (0.4%) had organisms detected on Gram stain. The overall sensitivity of Gram stain to detect bacterial meningitis was 67% [42 of 63; 95% confidence interval (CI): 54-78] with a positive predictive value of 60% (42 of 70; 95% CI: 48-71). Most patients without bacterial meningitis have negative Gram stain [specificity 99.9% (17,478 of 17,506; 95% CI: 99.8-99.9)] with a negative predictive value of 99.9 (17,478 of 17,499; 95% CI: 99.8-99.9). CONCLUSIONS: CSF Gram stain is appropriately used by physicians in risk stratification for the diagnosis and empiric treatment of bacterial meningitis in children. Although a positive Gram stain result greatly increases the likelihood of bacterial meningitis; the result may be because of contamination or misinterpretation in 40% of cases and should not, by itself, result in a full treatment course for bacterial meningitis.     

Test characteristics of the urine Gram stain in infants <or= 60 days of age with fever

OBJECTIVE: The utility of the Gram stain for the preliminary diagnosis of urinary tract infections (UTI) in infants or= 38.0 degrees C presenting to a pediatric emergency department during 2 consecutive winter seasons. Single pathogen growth of >or= 10(4) cfu/mL from a catheterized specimen and >or= 10(3) cfu/mL from a suprapubic specimen was considered positive. A positive Gram stain was defined as the identification of any organisms. Urinalysis was tested for the presence of nitrites and for leukocyte esterase (LE). Urine microscopy was analyzed for white blood cells per high power field (WBC/hpf). RESULTS: Fourteen of 246 patients were excluded; 11 because no Gram stain was completed. Of the remaining 232 patients, Gram stain had a sensitivity of 85.2% (95% CI 71.9-98.6%), a specificity of 99.0% (95% CI 97.7-100%), a likelihood ratio for a positive test of 87.3 (95% CI 21.8-349.9), and a likelihood ratio for a negative test of 0.15 (95% CI 0.06-0.37). There were 193 specimens for which a Gram stain and a complete UA and microscopy were completed and compared. Urine microscopy had a lower sensitivity and specificity than Gram stain for both >or= 5 WBC/hpf and >or= 10 WBC/hpf. In addition to the Gram stain, a dipstick negative for nitrites and LE had a low negative likelihood ratio (0.16), useful for decreasing the likelihood of a UTI. CONCLUSIONS: The Gram stain has excellent test characteristics for the preliminary diagnosis of a UTI in febrile infants. Patient disposition and therapy will likely change if clinical protocols and guidelines use the Gram stain rather than urine microscopy for preliminary diagnosis of UTI in infants.     

儿童梨状窝瘘41例

目的提高对儿童梨状窝瘘的认识，介绍相关诊断与治疗进展。方法报告41例梨状窝瘘病例，男16例，女25例，年龄9个月至12岁3个月；左侧40例，右侧1例；33例行颈部超声显像，20例行CT柃查，29例行甲状腺核素显像，39例行食管吞钡造影。28例手术治疗，其中20例应用胃镜辅助，并对37例进行随访，随访时间18个月至17年6个月。结果超声检查显示：32例病变侧甲状腺实质不均质占位或软组织实质不均质占位，与甲状腺关系密切；CT检查提示：病变侧颈部炎性肿块或合并甲状腺内炎性占位性病变，其中5例直接诊断为梨状窝瘘；核素显像提示：26例甲状腺左叶、特别是上极放射性稀疏，2例呈“冷结节”；食管吞钡检查显示：左侧或右侧梨状窝底部有垂直下行的细小瘘管。10例单纯切除术中8例治愈，2例复发，经胃镜辅助治愈；20例经胃镜辅助切除病例中，2例复发；13例未手术，其中9例获随访，5例自愈或未发作，4例仍反复发作。结论儿童梨状窝瘘炎症消退后食道吞钡检查可明确诊断，CT、B超及同位素检查在梨状窝瘘的诊断中也起着非常重要的作用，手术切除瘘管是主要的治疗方法，关键在于完整切除或消灭瘘管；胃镜辅助检查有助于瘘管的寻找，从而保证瘘管的完整切除，是一种简便、有效的治疗手段。     

"Massive hemoptysis" and shock after fever and cough北大核心CSCD

11岁男性患儿,因间断发热15 d,咳嗽10 d,“咯血”7 d入院。患儿15 d前以发热咳嗽起病,伴左侧颈部疼痛,抗生素治疗有效。病程中突然出现大“咯血”致休克,后经纤维支气管镜检查发现左侧梨状窝内瘘口并持续渗血,结合颈部及血管影像学检查考虑为先天性梨状窝瘘感染并颈部脓肿致颈内静脉受损血栓形成,通过低温等离子消融梨状窝瘘封闭术治疗后好转,随访1年半未反复。检索文献未发现梨状窝瘘感染引起大出血休克报道,该文总结此例患儿的临床特点及诊治经过,为早期诊断该类疾病及其并发症防治提供参考依据。     

Branchial fistula: CT manifestations

A patient with a recurrent left neck abscess was found to have a branchial fistula from the pyriform sinus. This uncommon anomaly was demonstrated by CT and barium swallow. The embryology, pathology and clinical features of this lesion are discussed and contrasted with those of the branchial cyst.